HomeMy WebLinkAbout040-1263-80-000 K
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and � � Division County:
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal informtion you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 384119
Permit Holdees Name: ❑ City ❑ Village ❑ own of: State Plan ID No.:
W illiams, Chris Troy Township
T BM E ev_: Insp. BM E ev.: BM Description: Parcel Tax No.:
5 l CST gnt, Z t�c.e = w�• -r-( ��•�+rre • 040 - 1263 -80 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic( Benchmark
Dosing - — Alt. BM 0.0 121.04. r
Aeration . Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet S. S 5
TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet
Air I
Septic �I, D r NA Dt Bottom —
Dosing NA Header/Man. f 2 "� 8 •S"7,
Aeration A Dist. Pipe f 2 . ('o fl $ • y
Holding Bot. System / ' ° o • C)
PUMP/ SIPHON INFORMATION Final Grade •�- 9.1 111. 1'
- : 1 7
Manuf urer and St cover Gr - ►ICE
Model Nu4dker GPM
TDH I Lift ion I S tem T Ft
Forcemaln I Length Dia. Dist.Towell
SOIL ABSORPTION SYSTEM )
4w4 RENCHI Width Length r No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
N • 19 . .... DIMENSION
LEACHING any act er:
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM r- S9Wt
INFORMATION Type O CHAMBER M c N m r:
System: 2$ 55 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold u Distribution Pipe(s) x Hole' x Hole Spacing Vent To A r Intake
Length Dia. ia. pacing 5
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over y Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center N. + Bed I Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes CO] No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: D21 AP/ 61 Inspection #2: • —f—f
Location: 413 New Cent D �ve, Hudson WI 54016 (NW 1/4 SW 1/4 5 T2 N R 9W) - 05 8191426 Frontier -Lot 18
1.) Alt BM Description- (o(, i 0 /ViC etch ¢l ��oweS �`^
2.) Bldg sewer length = 1 0
- amount of cover
� -3 W s �-t1 5 r ec�t�• -�`wte .
P n revision required. ❑ Yes No w
Use other side for additional information. 02 O
SBD -6710 (R.3(97) Date Inspectors Signature Cert. No.
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# AfI3 N E R- Sanitary Permit Application Safety & Buildings Division
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W A ILI E In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
s�n l� Personal information you provide may be used for secondary purposes Madison, W153707 -7302
Deportmeot;of;Commerce [Privacy Law, s. 15.04(ixm)] (Submit completed form to county if not
state owned.
Attach complete plans to the county copy only) for the system, on paper not less than 8 -1/2 x I 1 inches m size.
County State Sanitary P it Number Check if revision to previous application State Plan 1. D. Number
I. Application Information - Please Print all Information Location:
Property Owner Name Property Location
T /
r' . J t!�i� 1146 1/4 S J T N R' or
Property Owners Mailing Address Lot Number Block Number
. _ 1
City, State Zip Code Phone Numb& Subdivision Name or CSM Number
II. Type of Building: (check one) ❑ city
Q< l or 2 Family Dwelling -No. of Bedrooms : ❑ Village
❑ Public/Commercial (describe use):_ JRTown of -/
❑ State -Own Iro
Nearest Road
Parcel Tax Number(s) _ ..
III. T Ype of Permit: Check only oWe box on line A. Check box on line B if applicable
A) 1. kNew 2. ❑ Replacement 3. O Replacement of 4. 5. 6. 0 Addition to
System System Tank Only Existing System
B)
13 Permit Number Date Issued ,
A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) --'E — Ian '
(Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
• Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
• At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information:
1. Design flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Ele vation 7. Final Grade
Require } Proposed Rate (GalsJday /sq. ft.) (Minlinch) Elevation
G OD 5r./ V � s I r I v �Y • 0 ' \
VIL Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete strutted
Tanks Tanks
VIII. Responsibility Statement
I the undersi ed, assume responsibility for installation ofthe POWTS shown on the attached plans.
Plumbers Name (print) Plumber's Signa (no stamps): WARS No. Business Phone Number
o
a t "
Plumbers Address (Street, City, %ite, Zip Code
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IX. County/Departifient Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued g Agent Si (No stamps)
Approved 0 Owner Given Initial Adverse S Fee)
Determination � s7. CD e2 —05 2b& 1
X. Conditions of Approval /Reas ns for Disap r Val:
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code
A.C.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8' /z x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D.#
Prt of 040 - 1022 -10
APPLICANT INFORMATION - P aekprint all information. R viewed B y Date
Personal information you provide may be u tr secondary qurposes (Privacy Law, s. 15.04 (1) (m)). -
Property Owner r Property Location
Miller Sans Govt. Lot NW 1/4 SW 1/4 S 5 T 28 N,R 19 W
Property Owner's Mailing Address - n , , - Lot # Block # Subd. Name or CSM#
P.O. Box 151 18
City State Zip Code" ' Ph *umber ❑ City I] Village ®Town Nearest Road
Hudson W1 54016,,; 71 ..- 9 Troy
® New Construction ❑ Use: Residential /, -Nr O� `n,`h rooms 4 ❑Addition to existing building
❑ Replacement ❑ Pubkot describe
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ffs .8 trench, gpd/fts
Absorption rea required 857 bed, ft' 750 trench, ftz ' um design loading rate .7 bed, gpd/ft .8 trench, 9pd�
Recommended infiltration surface elevation(s) 106.50x ft (as referred to site plan ben mark)
Additional design / site considerations hlstall trenches using high capacity infiltrators.
Parent material Glacial outwash loud lain a va ,If a licable NA ft
S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system MS 0 u ® S❑ U ® S 0 u ® S❑ U ❑ S ®u ❑ S E u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure Consistence GPDlftz
Boring# Ho in. Munsell Qu. Sz. Cont. Color Texture t Sz Boundary Roots Bed Trench
1 1 0 -8 1Oyr2 /2 None sl 2msbk mvfr as 2fin,lc 0.5 0.6
2 8 -21 10yr4 /4 None sil lthinpl mfr aw 2fin,lc NP 0.3
Ground 3 21 -30 7.5yr4/6 None ifs lmsbk mvfr gw if &m 0.5 0.6
elev
114.15 ft 4 30 -71 10yr5 /4 None gr. s Osg dl gs - 0.7 0.8
Depth to 5 71 -124 10yr6 /4 None gr. s Osg dl - - 0.7 08 _
limiting
factor o ?
>124" �—
Remarks:
2 1 0 -11 1Oyr2 /2 None sill 2fcr mvfr as 2frn,lc 0.5 0.6
2 11 -25 10yr3 /3 None sil lthinpl mfr aw 2fin,lc NP 0.3 P'
Ground 3 25 -33 7.5yr4/4 None co. sl lmsbk dsh gw 1%m 0.4 0.5
elev
108.55 ft 4 33 -80 10yr5 /4 None gr. s Osg dl gs - 0.7 0.8
Depth to 5 80 -122 1Oyr6 /4 None s Osg dl - - 0.7 0.8
limiting
factor
>122' -
Remarks:
CST Name (Please Print) Signature: , �� -- - Telephone No.
James K. Thompson �.s � 715- 248 -7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, 454020 12/31/1999 3602 1167
PROPIRrYOVMER: Miller, Sam SOIL DESCRIPTION REPORT 1187 Page 2 of 3
•PARCEL LD.# Prt ofo40- 1022 -10 A-C.E. Sod & Site Evaluations
Depth Dominant Color Mottles Structure sistence Boundary Roots GPDIft2
Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Bed :Trench
3 1 0 -9 10yr2/2 None sil 2fcr mvfr as 2f &m 0.5 0.6
2 9 -21 10yr3 /3 None sil lthinpl mfr aw 2f &m NP 0.3
Ground
elev 3 21 -40 7.5yr4/6 None gr. Is Osg dl gw if &m 0.7 0.8
109.25 ft 4 40 -85 10yr5/4 None gr. s Osg FdI gs - 0.7 0.8
Depth to 5 85 -117 10yr6/4 None s Osg - - 0.7 0.8
limiting
factor -
>117' 33 Cl -
LL
Remarks:
4 1 0 -8 10yr2/2 None sl 2msbk mvfr as L2fin,Ic 1c 0.5 I 0.6
2 8 -20 10yr4 /4 None g a r ssl ` 2msbk mfr aw NP 0.3
Ground
elev 3 20 -27 7.5yr4/6 None Is Osg dl gw if &m 0.7 0.8
103.14 ft 4 27 -80 10yr5/4 None gr. s Osg dl gs - 0.7 0.8
Dew ip 5 80 -122 1 Oyr6 /4 None gr. s Osg dl - - 0.7 0.8
limiting
factor
>1
Remarks:
5 1 0 -8 10yr2 /2 None sl 2msbk mvfr as 2fm,lc 0.5 0.6
2 8 -29 1Oyr4/4 None sil lthinpl mfr aw 2frn,lc NP 0.3
Ground
elev 3 29 -40 7.5yr4/6 None Ifs lmsbk mvfr gw if &m 0.5 0.6
112.24 ft 4 40 -88 10yr5/4 None gr. s Osg dl gs - 0.7 0.8
Depth to 5 gg -113 10yr6 /4 None gr. s Osg dl - - 0.7 0.8
limiting
facto >113'
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
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.Z�YS
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83,54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms
Design Flow - Peak (gpd) 0
Estimated Flow - Average (gpd) 00
Septic Tank Capacity (gal) 12 6o W ae-�-s
Soil Absorption Component Size (W)
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) 1 .2w Z — as Rgl iks
Maximum Influent Particle Size (in) V 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. Th out et filte shall be cleaned as necessary to ensure
proper operatio The filter cartridge shoul not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
tic or other
entering a confined space. The atmosphere within the septic
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure i s designed g to accept domestic
I The limits of operation of this astewater from a residential facility. component are shown in p p
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
o
Went should be avoided articular)
or over the soil absorption coin particularly
Traffic around p p
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
r Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
sT cRoIX cOUNI`Y
SEPTIC TANK
MAINTE NANCE AGREEMENT
AM
4WNERSIIIP CERTIFICATION FORM
k
wner/B er
failing
ddress �7 f
ropesrty 4 rtment for new construction) - --�
(Verification required from Pla Depa
:tty /stat 1 Parcel Identification Number
TGAY �ESCRTI'TI
T om- N_g�W, .. Town of ray -- ---. --
'roperty ! _'!�, Sec. — __- /
Lot it 1 ..-
3ubdivisi on
Cer"I Survey Map #
Volume Page
wan-an y Deed # 3 7 ���
______, Volume Page #
Lot lines identifiable 5P Yes ❑ no
Spec 1'0 p yes no
#Sff ' rema ture failure to handle wastes. Proper maintenance
roper use and maintenanceof your septic system cou result in its a licensed pumper. What you put into the system
umping out the septic tank every three years or sooner, if needed y
consists e function of the septic tank as a treatment stage
in the waste disposal system,.
Dc arlment a certification form, signed by the owner � s ystem
e property owner agrees to submit to St. Croix 'Zoning p that (1) the o11-site was tewater disposal Y
utastcrpl jourueymanplumbcr, actedplumberoralicensedpumperW�Y�
o rating condition and/or (2} after inspection and pumping (if necessary), the septic tank is l ess than 1/3 f of sludge.
is m p pe system with the standards
ed have read the above requirements and agree to maintain the private sewage d certification
Uwe: the undersign D of Natural Resources, State o€ Zonin s office within 30
set forth, herein, as set by the Department of Commerce and the
stating t your septic system: has been maintained must be completed and returned to the St. Croix County Zoning
days of I he three year expiration date.
DATE
7sK A IM OF APPLICA.NU
UW g. ,CER n _FICATI0 our knowledge. I (we) am (are) the owners) of
I (we) certify that all statements an this form are t ru e the best of te of Deeds Office.
the property descri Bove, by virtue of a warranty deed rec to
in Reg
i f
0 6 4 O / FAPPL DATE
CANT * «* « ««
i ermit being revoked by the Zoning Department, « « « +• Any information that is mis- represeatedmay result in the sanitary p
*s Inc' ude with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
I
VOL 1579PAC� 335
STATE BAR OF WISCONSIN FORM 2 - 1998 1�3 s�
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between Sam E. Miller, a 01 -29 -2001 8:00 AN
single person,
WARRANTY DEED
EXEMPT N
Grantor, CERT COPY FEE:
and Chr istopher -- g. Williams and COPY FEE:
Jacqueline A.. Williams, husband and TRANSFER FEE: 195.00
wife as survivorship marital property, RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Cro i X County, State of Wisconsin:
Recording Area
Name and Return Address
First Federal Savings Bank
LaCrosse— Madison
201 South Second Street
Hudson, Wisconsin 54016
040 - 1263 -80 -000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Lot 1 Plat of Frontier in
the Town of Troy, s "Croix
County, Wisconsin.
j'
I
I'
� Exceptions to warranties: ;
Su
bmect to easements, reservations and restrictions or record.
Dated this day of January 2001
SEAL` SEAL
* SAM E. MILLER
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
State of Wisconsin,
55.
St. Croix Coon
authenticated this day of Personally came before me this day of
January 2001 , the above named
Sam E. Miller
TITLE: MEMBER STATE BAR OF WISCONSIN to
(If not, $ 6t m known to be the person who executed the foregoing
authorized by §706.06, Wis. Stats.) ,O S =sltument and acknowledge the same.
J �lC_'d li
THIS INSTRUM
ll wAs DRAFTED BY wil��3`I EGr
UNLAP uun
Hudson, Wisconsin Not ry P blic State of Wisconsin
My co mission is perman t. (If not, state expiration date.
(Signatures may be authenticated or acknowledged. Both are not ` A 0
necessary.)
i
* Names of persons signing in any capacity must be typed or printed below their signature. 1
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis.
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